Pain perception disparities: why women’s pain is frequently overlooked

It has been an eventful August in the Western Kenya belt as the young boys underwent their rites of passage in colourful ceremonies. It was quite fascinating to drive through the region, meeting groups of people singing and dancing along the road, while beating drums, hoping to catch sight of a strapping young man herding off a bull intended for slaughter later in the evening.

The age-old practice of circumcising boys has evoked many conversations lately, especially about pain. This is after a video of a traditional surgeon expertly performing the cut surfaced online.

The young men are circumcised at dawn, with a dip in the cold water serving as anaesthesia. Though many boys will now have the procedure done in a hospital, the traditional practice is still widely held dear.

Pain perception and the beliefs around it is a topic on its own! Generally, women will experience pain more frequently than men throughout life, especially in the reproductive period.

From adolescence, menstrual pain is a common cause of pain for girls, persisting through to menopause. Pregnancy brings with it the possibility of miscarriage as a source of pain; even before we address the pain of childbirth.

Women are also more likely to undergo surgical intervention, whether as a result of child-bearing resulting in ectopic pregnancy or at caesarian section; or due to reproductive health conditions such as fibroids, endometriosis, or ovarian cysts.

This is not to say that men do not encounter pain through the cycle of life, but generally, they are blissfully spared from a lot of causes by virtue of their gender. The proportion of medical conditions resulting in pain is far lower in men than in women.

This has inadvertently resulted in biases of how pain is perceived, both by the person experiencing it and by those around them.

Right from the community, on one hand, pain in men is likely to result from dramatic reasons such as pain from trauma, road traffic accidents, physical altercations, workplace injury and acute surgical emergencies.

On the other hand, women are likely to experience pain from chronic or recurring causes, leading to inadvertent normalization of such pain as period pain or the pain of childbirth. Over time, women are expected to bear the pain stoically because this pain is ‘expected’, hence one should have learnt to ‘live with it’.

A publication by Diane E. Hoffmann and Anita J. Tarzian in the Journal of Law, Medicine and Ethics, The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain; heavily dissects literature through the decades about this topic.

The article highlights the persistence of bias against women’s pain through perceptions of healthcare providers’ existing notions such as, “Women complain more than men; women are not accurate reporters of their pain; men are more stoic so that when they do complain of pain, "it's real"; and women are better able to tolerate pain or have better-coping skills than men.”

Some of the key areas of emphasis that Hoffman and Tarzian’s review of evidence pointed out include the finding that while women have a higher prevalence of diseases associated with chronic pain than men, and that they are biologically more sensitive to pain than men, and that they respond differently to certain analgesics, their pain reports are taken less seriously than men's, and, they receive less aggressive treatment than men for their pain.

Additionally, research also noted that women have more coping mechanisms to deal with pain. Unfortunately, this may contribute to a general perception that they can put up with more pain, hence their pain does not need to be taken as seriously.

This has directly affected healthcare providers' response to pain management in hospitals, both in the wards and in the ambulatory (outpatient) department.

Even more disturbing was the finding that although women reported pain more frequently to a healthcare provider, they were more likely to have their pain reports discounted as "emotional" or "psychogenic" and, therefore, "not real."

By default, women were assumed to have no pain if they looked more physically attractive, yet they were more likely to take care of their physical appearance than men, even in the face of pain.

Inadvertently, the pain perception discrimination is worse where the women facing pain have to live with chronic pain conditions such as sickle cell disease, fibromyalgia, migraine, osteoarthritis, rheumatoid arthritis, lupus and irritable bowel syndrome. Even worse is that most autoimmune conditions that cause chronic pain, tend to be more common in women than men.

As a result of these perceptions, there are many medical procedures for women that have been handled so callously over the years, with the pain and discomfort they evoke, being grossly undermined by healthcare providers.

These include commonly performed procedures such as vaginal examinations during labour to ascertain how far the cervix has opened, pap smear, insertion of contraceptive intrauterine devices, performing of the dreaded hysterosalpingogram (HSG), a special X-ray to determine whether the woman’s fallopian tubes are patent or blocked, and the more advanced office-based hysteroscopy (use of a specially mounted camera to look into the uterus to diagnose uterine conditions and take specimen biopsies for tests).

Even the care providers themselves will debate about the level of pain a woman is likely to experience during these procedures and whether pain relief is warranted.

What is wrong with this particular argument is the fact that in the first place, pain is a subjective assessment. As an individual, you are the only one who can quantify your pain, irrespective of the cause.

No two people will experience the same pain response to a noxious stimulus. This is because pain perception is a result of a complex interaction of the physiological, biochemical, hormonal, and psychological aspects of an individual, to interpret the stimulus.

Therefore, where one woman will breeze through their pap smear with ease, another one will be traumatized by the same, even when the care provider technique is the same. Both their experiences are valid, and their pain perception is too.

Pain exists for a reason. It is a warning by your body to alert you that something is not quite right. When your fancy German car lights up a warning sign on the dashboard, just because the car keeps moving does not mean it does not need to be attended to.

Alleviating pain starts with unlearning the negative culture of downplaying pain and instead, learning a whole new culture of acknowledgement, empathy and shared decision-making in alleviating pain. This applies to both patients and the care providers.

Eve may have eaten the apple in the Garden of Eden, but the women of today were not even born. It is time to stop punishing them for the indiscretions of their ancestor!

Dr Bosire is an obstetrician/ gynaecologist